QUERI – Quality Enhancement Research Initiative

Go to the HSRD website

Quality Improvement Methods

38. Pull

a. Definition: A sequence of processes or flow of work often works best under conditions where the work is "pulled" through the system rather than "pushed". This effect was noticed when the Toyota Production System (also referred to as the Lean method, see Section 24) was initially developed. Having each step pull work from the prior step resulted in less inventory in process, less waiting and less waste. When workers push completed work forward into an inventory waiting for the next worker, the lack of connection is a problem. In healthcare this may represent the movement of patients waiting because they have completed one step and are waiting for the next.

b. Literature:

Most of the literature on Lean in healthcare addresses the desirability of pull vs. push or just-in-time systems and gives examples of its use.

c. Example:

A diagnostic imaging department was experiencing less patient throughput than other departments of a similar type. Observance of the flow through the MRI area discovered considerable waiting by patients and that the equipment not fully utilized even though the equipment was staffed with the necessary technicians. It turned out that movement of patients from the waiting room to an available MRI was the responsibility of a clerk in the waiting area. When a technician completed working with a patient, the patient was sent to an exit area and the technician waited for the next patient sent by the clerk. Thus the clerk "pushed" the patients to the MRI machine. A better arrangement was to have the technician go get a patient from the waiting area when done, thus "pulling" patients forward. A considerable increase in patient throughput occurred.